You know and I know that doctors ask for too many pre-op exams, which aren't supported by the evidence. Cataract surgery is one egregious example. There is already a lot of evidence that such testing doesn't work, and one of my colleagues is looking more deeply into the reasons. Here are two stories from my daily practice about the frustrations and satisfactions at trying to do the right thing, in however small a way: two steps forward and 1.9 (or 2.1) steps back.

A patient came to me to get "pre-opped" for her cataract removal. The thing is that cataract removal, as low-risk as it is, doesn't need any preoperative examination in patients at normal risk.

But, things being what they are, she came with the handout that she was sent, and I set about trying to figure out who, exactly, wanted these exams. This episode I entitle, therefore

Adventures in unneeded pre-op for cataract surgery 1. The surgeon says the anesthetist wants it 2. The anesthetist says the administrator requires it 3. The administrator says the board "considered [getting rid of preop tests for cataract removal]" 2 years ago but was concerned how it would look to other hospitals in the area

And she told me to talk to the medical director.

I reached the medical director. He said, "You're right. And I'm so frustrated! They [!] are tying my hands." "Who's 'they'?" "The policy." "But didn't you ---?" "The board decided it. There are so many more requirements these days. You know that Medicare won't pay if there's a new infection." "But that's different. That's evidence based." "Medicare requires [these preop tests] for cataract surgery." "They do? I don't think that's true. And don't you know about the Choosing Wisely recommendations [not to do such preop tests]?" "I do. But In any case," he continued -- dogs barked in the background ("I'm working from home") -- "we can't change policies since it's the norm now." I told the patient about all this. "I can understand if you choose to go with your previously scheduled surgery, and I would order the tests if you wanted to keep it." She chose to get re-evaluated at our ophthalmology center. For all of Hopkins's imperfections, Wilmer is doing a great job of moving towards fewer contraindicated preop tests. A partially happy ending! And that medical director DID say, "Your phone calls have put this issue on the radar."* * *

Before you start smiling and drawing rainbows and unicorns, though, I'll tell you about a patient I saw that same day, who came to be "pre-opped" not for cataract removal but for (low-risk) plastic surgery. She told me, "Your secretary already checked with [the surgeon's] office, and they said they wouldn't touch me without these tests."

So I ordered them, because the patient wanted them.

Net win? Net loss? Somewhere in between?

Or just another up-and-down day, trying to move the blip in a system which is resistant to change and still, endemically, prone to overuse because "someone" thinks these tests are necessary.